MEDCOM Medication Management Discussion 2009 MEDCOM-TJC Conference Manager, Army Patient Safety Program Quality Management Office HQ, US Army Medical Command Fort Sam Houston, TX 19 Nov 2009
BRIEFING OUTLINE PURPOSE: To provide an update on medication management trends observed in the Army Medical Department. Medication Storage Medication Orders Medication Review Status of the Waiver Medication Review When No 24 hr Pharmacy Service Automated Dispensing Cabinets - Overrides Slide 2 of 27
Medication Storage Slide 3 of 27
Medication Storage & Security Importance Medication storage is designed to: assist in maintaining medication integrity promote the availability of medications when needed minimize the risk of medication diversion reduce potential for dispensing errors Law and Regulation and manufacturers guidelines further define the hospital s approach to medication storage The Joint Commission, Hospital Accreditation Standards, 2009 Slide 4 of 27
Medication Storage & Security Scenarios Heparin 10,000 units/ml stored in ADC instead of 1,000 units/ml If medications for 1 st dose are in the ADC, pharmacy review may be by-passed (override) Unsafe quantities of medications in the ADC bulk bottle of liquid medication Healthcare professionals with substance abuse issues find ways to divert medications from ADC Expired medications in locked utility room Slide 5 of 27
MM.03.01.01, EP 2 Medication Storage Store medications according to manufacturer s recommendations Best Practices: Temperature Monitoring Centralized Monitoring System Wireless Monitoring System Alarm Dialing Monitors SensaPhone TempTrak ThermaViewer Slide 6 of 27
MM.03.01.01, EP 2 Medication Storage Continuous monitoring of temperature Staff must understand their responsibilities: Temperature monitoring Resolving problems related to out-of-range temps Staff training component Watch out for those refrigerators in areas not staffed 7 days/week Digital thermometers may be an answer Slide 7 of 27
MM.03.01.01, EP 3 Medication Storage Prevent drug diversion Scheduled drugs are locked Usage record is maintained Discrepancies are resolved Define resolution process Define process of wasting Access to automated cabinet is current Staff must log out of automated cabinets Electronic reporting to identify potential diversion Slide 8 of 27
MM.03.01.01, EP 7 Medication Storage Multi-Dose Vials (MDV) USP Chapter 797-28 days beyond use date Date MDV with expiration date Best Practices: Minimize use of MDV Document: date opened and expiration date (28 days from day MDV is penetrated) Pre-printed labels available Health Care Logistics, Inc Medi-Dose/ EPS, Inc PHARMEX/ TimeMed Slide 9 of
MM.03.01.01, EP 7 Medication Storage Brooke Army Medical Center, Department of Pharmacy, Fort Sam Houston, Texas Slide 10 of 27
MM.03.01.01, EP 7 Medication Storage Beyond Use Date Contrast media and warmers Solution bags/bottles and warmers Glucometer strips Slide 11 of 27
MM.03.01.01, EP 10 Medication Storage Most ready-to administer forms available from manufactures Contrast media, heparin, saline flush, others Insulin pens Unit-doses repackaged by the pharmacy or a licensed packaging company Slide 12 of 27
MM.03.01.01, EP 18 Medication Storage Periodic inspection of storage areas Inpatient and outpatient areas Appropriately train staff Unannounced inspection Communicate findings with leadership Slide 13 of 27
MM.03.01.03 Emergency Medications Issue Emergency medications selection Process in place to replace emergency medications & supplies when needed Best Practices: Maximize use of unit-dose, age-specific, ready-to-administer Pediatric dosing guidelines Broselow Pediatric Emergency Tape Emergency medications are secure Slide 14 of 27
MM.03.01.05 Medications Brought In Defines when medications brought in by patient or LIP can be administered Prior to use, identification and visual evaluation of integrity Inform prescriber/patient if medications brought in are not permitted Slide 15 of 27
Medication Orders Slide 16 of 27
MM.04.01.01 (MM 3.20) Medication Orders Specific Findings EP 1 1 Observation Written policy address the required elements of a complete medication order. EP 6 3 Observations The hospital specifies the required elements of the following types of orders that it deems acceptable for use: As needed (PRN) orders Standing orders Hold orders Automatic stop orders Resume orders Titrating orders Taper orders Range orders Orders for compounded drugs or drug mixtures not commercially available Orders for medication-related devices Orders for investigational medications Orders for herbal products Orders for medications at discharge or transfer Slide 17 of 27
MM.04.01.01 (MM 3.20) Medication Orders Specific Findings EP 13 5 Observations Policies and procedures regarding medication orders are implemented. Recommendations PRN Orders Indication Acetaminophen pain or fever? Therapeutic duplication which one 1 st? 2 nd? Range Orders Use only one variable (i.e. dose or dosing interval) Define required elements of a complete medication orders Must include route of administration Pre-printed Orders Check electronic and paper pre-printed orders Forms Committee, P&T Committee, etc. No Blanket Orders Slide 18 of
Medication Order Review Slide 19 of 27
MM.05.01.01 (4.10), EP1 Medication Orders Review TJC/DoD Protocol Exempts DoD from fully complying with this standard Real-time pharmacist review of all prescriptions is not possible in outpatient settings Not intended for inpatient settings Relies on CHCS Clinical Screening capability and quality of the DoD Pharmacy Technician Training Program Not intended for civilian Pharmacy Technicians Requires an annual report to TJC charting progress toward full compliance DoD must be in full compliance NLT 2011 Slide 20 of 27
MM.05.01.01 (4.10), EP1 Medication Orders Review Justify and create new pharmacist positions Place pharmacists in: TMC Pharmacy Refills Pharmacy Commissary Pharmacy PX Pharmacy Utilize Technology: Telepharmacy Slide 21 of 27
MM.05.01.01 (4.10), EP1 Emergency Room Medication orders written by ED providers for immediate administration Current interim still in effect No review required if LIP present in immediate area. Retrospective review of a sample of orders by pharmacy Prescriptions written by ED providers This issue falls under the purview of LIPs able to dispense medications. The process of dispensing is regulated by state law and regulations (DoD not subject to it) So it depends on policy and procedure As long as the physician is involved in the process and hands medication to the nurse to give to the patient, there is no issue Slide 22 of 27
MM.05.01.01 (4.10), EP 2 Medication Orders Review When an on-site licensed pharmacy is not open 24 hours a day, 7 days a week, a health care professional determined to be qualified by the hospital reviews the medication order in the pharmacist s absence What is required to conduct an appropriate review of a medication order? Is the identified health care professional competent to conduct the review? Is the competency documented? Slide 23 of 27
Appropriate Review of an Order More than the Five Rights All medication orders are reviewed for the following: Patient allergies or potential sensitivities Drug-drug and drug-food interactions Appropriateness of the medication dose, frequency, and route of administration Current or potential impact as indicated by laboratory values Therapeutic duplication Other contraindications Variation from the hospital s approved indications for use Slide 24 of 27
MM.05.01.01 (4.10) Medication Orders Review Automated Dispensing Cabinets (ADC) Overrides Definition - Retrieval of medications from the ADC prior to pharmacy review Criteria should allow emergency access when appropriate Implement strategies that reduce the risk of medication error: Limiting the quantity and number of drug concentrations available Minimizing use of multi-dose containers Check the drug and dose against the patient s allergies and weight as appropriate Provide medication preparation instructions (to reconstitute or dilute medications) Require an independent double-check with another licensed healthcare provider Requiring documentation of override rationale Develop a required staff competency assessment Override policy is approved by P&T Committee, or their equivalent group Routinely review override reports to identify and address barriers for review Slide 25 of 27
Institute for Safe Medication Practices (ISMP) Recommendations Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets 2008 12 core processes to influence the safe use of ADCs Medication Safety Self-Assessment for Automated Dispensing Cabinets 2009 PSC/Pharmacy Initiative Ten MTFs are completing self assessment tool Goals: MM.05.01.01 (4.10) Medication Orders Review To assess medication safety with ADC in the MEDCOM Provides tool and recommendations to improve safety with ADCs Slide 26 of 27
Questions?? Slide 27 of 27